Accolade Healthcare Danville

Inspectors wroteBased on interview and record review, the facility failed to provide the required 30 day notice to a resident discharged involuntarily. This failure affects one resident (R2) out of seven reviewed for discharges on the sample list of eight.

Inspectors wroteBased on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for four (R1, R2, R3, R6) residents of six residents reviewed for call light response in a sample of ten residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (R1) of three residents reviewed for employee-to-resident verbal abuse on a sample list of three residents. The facility failed to ensure R1 was protected from ongoing verbal abuse, degrading interactions, intimidation, and emotionally distressing treatment. The facility further failed to appropriately respond to prior concerns involving the same staff member and failed to ensure resident dignity and emotional well-being were maintained. These failures resulted in R1 feeling emotional distress, tearfulness, frustration, feelings of being degraded, and disbelieved. [...]

Inspectors wroteBased on interview, record review, and facility documentation, the facility failed to timely report allegations of abuse, neglect, injury of unknown source, and mistreatment involving one resident (R1) in accordance with facility policy and federal regulations on a sample list of three residents. The facility failed to immediately report allegations to the Administrator, physician, and other required officials after staff became aware of allegations involving verbal abuse, rough handling, and injury to R1's left foot by a Certified Nursing Assistant on 5/2/2026. Findings Include: On 5/2/2026, R1 alleged that V9 Certified Nursing Assistant (CNA) forcefully pulled a wheelchair and struck R1's foot during care, causing pain and bruising. R1 further alleged V9 had previously degraded and verbally mistreated R1. [...]

Inspectors wroteBased on interview, record review, and facility documentation, the facility failed to thoroughly investigate allegations of abuse and failed to implement timely interventions to protect one (R1) from further potential abuse and emotionally distressing interactions involving Certified Nursing Assistant (CNA) on a Sample list of three residents. The facility failed to adequately respond to prior allegations of degrading behavior, failed to ensure effective follow-up after a care plan meeting addressing resident concerns, failed to remove the alleged staff member from resident care after repeated complaints, and failed to complete a timely and thorough investigation into allegations of verbal abuse and rough handling on 5/2/2026. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to assess one resident (R1) for safety to self-medicate of three residents reviewed for self-medication in a sample list of eight residents. Findings Include:R1's Care Plan updated 10/2/25 includes the following diagnoses: Open Wound to the Abdominal Wall, Polyneuropathy, Spondylosis, Severe Obesity, Reduced Mobility, Repeated Falls, Chronic Clostridium Difficile, History of MRSA (Methicillin Resistant Staphylococcus Aureus), and History of Total Knee Replacement. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and totally dependent on staff for mobility and incontinence care. There is no documentation of a self-medication assessment documented in R1's electronic medical record. R1's Care Plan does not address self-medication. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide incontinence care/catheter care in a timely manner and failed to maintain a urinary catheter bag below the level of the bladder for one resident (R1) and failed to use appropriate hand hygiene for another resident during incontinence care (R5) of three residents reviewed for incontinence care in a sample list of eight residents. Findings Include:R1's Care Plan updated 10/2/25 includes the following diagnoses: Open Wound to the Abdominal Wall, Polyneuropathy, Spondylosis, Severe Obesity, Reduced Mobility, Repeated Falls, Chronic Clostridium Difficile, History of MRSA (Methicillin Resistant Staphylococcus Aureus), and History of Total Knee Replacement. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and totally dependent on staff for mobility and incontinence care. [...]

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to prevent a fall with injury by failing to provide adequate staff assistance during a therapy session for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling forward out of a bed and landing on the floor and hitting R1's head on the floor. R1 sustained a laceration to the head which required emergency treatment and 15 staples to close. Findings Include:R1's Emergency Department Notes dated 10/31/25 at 6:15PM document R1 has a laceration and received 15 staples to the frontal part of the head due to a fall. R1's Progress Note dated 10/31/25 documents Therapy informed this nurse that resident fell. She reported that she had resident sitting on the side of the bed and she walked to other side of bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately code the minimum data sheet (MDS) for three (R24, R38, R76) of 17 residents reviewed for MDS accuracy in a sample size of 38.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with fingernail care, eating, and shaving for four of four residents (R24, R26, R190, R38) reviewed for Activities of Daily Living in the sample list of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent and treat pressure ulcers and failed to complete initial wound assessments for three residents (R24, R84, R140) of five residents reviewed for pressure ulcers in a sample list of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered for three of nine residents (R24, R50, R78) reviewed for medication administration in the sample list of 38. This failure resulted in three medication errors out of 25 opportunities, a 12% medication error rate.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately label and store medications and account for controlled medications for five of 16 residents (R40, R61, R71, R192, R63) reviewed for medication storage in the sample list of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate contact droplet precautions for two residents (R36, R69) and failed to sanitize a blood glucose meter following use to prevent cross contamination for one resident (R24) of 17 residents reviewed for infection control in a sample list of 38. Findings Include: The facility's Glucose Meter Cleaning policy dated July 2019 documents clean and disinfect the blood glucose meter after each use with an Environmental Protection Agency approved cleaner. The facility's policy Transmission Based Precautions revised April of 2025 documents In order to prevent the spread of communicable diseases isolation will be initiated according to CDC (Center for Disease Control) transmission based guidelines. [...]

Inspectors wroteBased upon observation, interview and record review, the facility failed to maintain or improve range of motion and contractures following recommended restorative program for one (R76) of four residents reviewed in a sample size of 38.

Inspectors wroteBased on observation, interview, and record review the facility failed to check gastric residual volume during gastrostomy tube (g-tube) medication administration for one of two residents (R26) reviewed for g-tubes in the sample list of 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin to the state agency (Illinois Department of Public Health) in the required two hour time frame. This failure affects one resident (R1) out of three reviewed for injuries on the sample list of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a fall prevention intervention according to a resident's care plan. This failure affects one resident (R1) out of three reviewed for fall prevention on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement skin and pressure relieving interventions, evaluate nutritional status, maintain wound dressings, and accurately document wound assessments for three (R1, R3, R4) of three residents reviewed for pressure ulcers in the sample list of four. These failures resulted in R4 developing a stage two pressure ulcer that deteriorated into an unstageable pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent resident received repositioning for one (R2) of three residents reviewed for repositioning on a sample list of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and assess for significant weight loss and ensure nutrition/weight loss was evaluated by the physician and dietitian for one (R3) of three residents reviewed for weight loss in the sample list of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for three (R1, R3, R4) of three residents reviewed for pressure ulcers in the sample list of four.

Inspectors wroteBased on interview and record review the facility failed to routinely assess and monitor a bruise/hematoma (bruising with blood pooling underneath the skin), update the physician, and assess and measure post-surgical wounds upon readmission for one of three residents (R1) reviewed for wounds in the sample list of four. This failure resulted in R1's left foot bruise/hematoma becoming infected and requiring hospital operative incision and draining (I&D).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide fingernail care for one of three residents (R3) reviewed for hygiene in the sample list of four.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement pressure relieving interventions to prevent the development of pressure ulcers, and failed to measure, assess, and report pressure ulcers for two of three residents (R2, R3) reviewed for wounds in the sample list of four.

Inspectors wroteBased on observation, interview and record review the facility failed to implement effective fall interventions in three (R1, R2, and R3) of three residents reviewed for falls. These failures resulted in R1 sustaining a head laceration with an arterial bleed, requiring nine sutures and R2 sustaining bilateral fractured wrists resulting in decreased independence, both as the result of falls.

Inspectors wroteBased on interview and record review the facility failed to timely notify the physician of newly developed, draining wounds for one (R1) of four resident reviewed for wounds in the sample list of six.

Inspectors wroteFailures at this level requires more than one deficient practice statement: A. Based on observation, interview, and record review the facility failed to culture a residents' draining wound prior to initiating antibiotics, assess a residents' surgical incision upon admission to include measurements/description of the surgical wound, and accurately transcribe wound treatment orders for three (R1, R2, R6) of four residents reviewed for wounds in the sample list of six.

Inspectors wroteBased on observation, interview, and record the facility failed to assess and measure a pressure ulcer upon admission for one (R2) of four residents reviewed for wounds in the sample list of six.

Inspectors wroteBased on observation, record review and interview, the facility failed to employ a clinically, qualified Director of Food and Nutrition Services. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain facility kitchen equipment in a clean, sanitary condition, to prevent potential cross-contamination and food-borne illness. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have required members attend Quarterly Quality Assurance (QAA) meetings. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rights to dignified activities of daily living. This failure affects six of six (R2, R38, R49, R72, R73, R77) residents reviewed for dignity on the sample list of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately encode a resident's health status on the Resident Assessment Instrument (Minimum Data Set) regarding dialysis. This failure affects one of two residents (R92) reviewed for dialysis on the sample list of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide PRN (as needed) dressing changes for a resident. This failure affects one resident (R7) reviewed for dressing changes in the sample list of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to provide and implement fall interventions to prevent falls for a resident. These failures affect one of one resident (R29) reviewed for accidents/supervision on the sample list of 24.

Inspectors wroteBased on interview and record review, the facility failed to administer two physician ordered intravenous antibiotic medications on two consecutive days resulting in a delay in treatment for one resident (R7) of one resident reviewed for significant medication errors in the sample list of 24.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain complete and accurate medical records for one of two residents (R92) reviewed for dialysis/medical records on the sample list of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to wear a gown during high-contact resident wound care activities in accordance with the physician order, and the infection control enhanced barrier precaution policy. This failure affected one of three residents (R9) reviewed for pressure ulcers/wounds on the sample list of 24.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional air mattress to prevent a fall from bed; failed to thoroughly investigate the environment to determine a targeted root cause to repair or replace the air mattress for R2; and failed to safely transfer a resident (R5) by full mechanical lift, from a wheelchair to recliner chair. These failures resulted in R2 sustaining a head injury and laceration requiring emergency medical care at a local hospital and R5 to get hit in forehead with mechanical lift equipment causing mild swelling and abrasion. R2 and R5 are two of five residents reviewed for accidents/accidents on the sample list of 11. Findings Include: 1.) R2's admission Record documents R2's initial admission date as 11/20/23. It includes the following diagnoses for R2: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain residents' dignity by failing to provide timely incontinence care for two of six residents (R9 and R10) reviewed for delay in treatment/abuse/dignity on the sample list of 11.

Inspectors wroteBased on record review and interview, the facility Administrator failed to recognize and timely report an allegation of staff to resident physical abuse to a law enforcement agency for one of six residents (R4) reviewed for abuse on the sample of 11

Inspectors wroteBased on record review and interview the facility failed to maintain complete and accurate medical records by failing to document R10's history of abuse on R10's abuse risk assessment. These failures affected one of eight residents (R10) reviewed for accidents /abuse on the sample list of 11.

Inspectors wroteBased on interview, and record review, the facility failed to follow an order for pain medication as written by the pain specialist for one (R1) of three residents reviewed for pain in a sample of three residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent the development of residents pressure ulcers, administer treatments as ordered, develop/implement pressure relieving interventions, accurately assess risk for developing pressure ulcers, accurately assess pressure ulcers, timely notify the physician to obtain treatment orders, and notify the resident representative of pressure ulcers. These failures affect three of five residents (R37, R64, R51) reviewed for pressure ulcers in the sample list of 55 residents. These failures resulted in R37 developing a left hip deep tissue injury (DTI) that deteriorated to an unstageable wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision to prevent a fall, implement fall interventions, and complete post fall neurological assessments for one resident (R23) reviewed for falls in the sample list for 55 residents. This failure resulted in R23 falling, causing head and facial trauma/bruising, and an emergency room evaluation.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent weight loss, record meal intakes, implement nutritional recommendations, ensure weight loss was timely evaluated by the dietitian, notify the physician and family, and evaluate the effectiveness of nutritional supplements for three (R37, R18, R50) of five residents reviewed for nutrition in the sample list of 55. This failure resulted in R37 experiencing a significant weight loss of 13.59 % between August and September 2022 and an additional significant weight loss of 8.37% between 11/23/22 and 11/30/22.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pain control to one (53) of two residents reviewed for pain from a total sample list of 55. This failure resulted in severe pain for R53 during a wound dressing change.

Inspectors wroteBased on interview and record review the facility failed to have the required members of the Quality Assessment and Assurance Committee in attendance at its quarterly Quality Assurance meetings. This failure has the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to prevent the spread of disease to other residents. Failures include display of proper signage for COVID-19 (Human Coronavirus); wearing appropriate Personal Protective Equipment (PPE) into infectious resident rooms; wearing PPE as indicated during staff and resident testing for COVID-19; educate/encourage COVID-19 positive resident about measures to prevent infecting others, and pulling curtains during respiratory care in rooms with two residents. These failures affect 13 residents (R3, R9, R10, R16, R19, R30, R39, R66, R67, R79, R81, R142, R238) reviewed for infection control on the total sample of 55. These failures have the potential to affect all 88 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to invite residents and their family members to care conferences for care planning purposes in four (R28, R53, R68, R74) of 24 residents reviewed for care plans from a total sample list of 55.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist with nail care for four (R11, R3, R18, and R37) of 24 residents reviewed for assistance with ADLs (Activities of Daily Living) on the sample list of 55.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and failed to administer Gastrostomy tube medications separately for two of four residents (R47, R138) reviewed for medication administration in the sample list of 55. The facility had 4 medication errors out of 25 opportunities resulting in a 16% (percent) medication error rate.

Inspectors wroteBased on observation, interview and record review the facility failed to store residents medications separately from food. This failure affects 10 residents (R338, R47, R6, R36, R43, R82, R53, R138, R76, R40) with medications in the medication room refrigerator in the sample list of 55.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders and weigh a resident at risk for rapid weight fluctuations due to dialysis treatment. This failure affects one (R40) of seven residents reviewed for weights from a total sample list of 55.

Inspectors wroteBased on observation, interview, and record review the facility failed to store respiratory equipment in a sanitary manner, obtain order for oxygen administration, and obtain an order for respiratory equipment changes for two of two residents (R5, R47) reviewed for respiratory equipment on the sample list of 55.